- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $12.88
| Facility | 26 | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $33.11 / $47.86
| Facility | TC | $33.11 | $33.11 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $52.48 / $120.23
| Professional | | $40.74 | $52.48 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $15.14 / $60.26
| Professional | 26 | $12.02 | $15.14 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $33.11 / $93.33
| Professional | TC | $28.18 | $33.11 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $107.15 / $131.83
| Professional | | $85.11 | $107.15 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $30.90 / $38.90
| Professional | 26 | $24.55 | $30.90 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $75.86 / $93.33
| Professional | TC | $60.26 | $75.86 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $69.18 / $316.23
| Professional | | $42.66 | $69.18 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $26.30 / $107.15
| Professional | 26 | $16.98 | $26.30 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $44.67 / $295.12
| Professional | TC | $28.18 | $44.67 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $95.50 / $104.71
| Professional | | $87.10 | $95.50 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $28.18 / $40.74
| Professional | 26 | $26.92 | $28.18 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $64.57 / $67.61
| Professional | TC | $60.26 | $64.57 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Professional | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Professional | 26 | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $60.26
| Professional | TC | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $74.13 / $87.10
| Professional | | $54.95 | $74.13 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $24.55 / $28.84
| Professional | 26 | $17.38 | $24.55 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $45.71 / $60.26
| Professional | TC | $36.31 | $45.71 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $79.43 / $114.82
| Professional | | $48.98 | $79.43 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $26.92 / $37.15
| Professional | 26 | $15.85 | $26.92 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $53.70 / $70.79
| Professional | TC | $32.36 | $53.70 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $89.13 / $89.13
| Professional | | $75.86 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $26.92 / $26.92
| Professional | 26 | $22.91 | $26.92 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $63.10 / $63.10
| Professional | TC | $53.70 | $63.10 | $63.10 |